A recent report from the House Committee on Oversight and Accountability highlights concerns about pharmacy-benefit managers (PBMs) directing patients toward more expensive medications and limiting their pharmacy options. The findings emerged from a 32-month investigation and were reported ahead of a scheduled hearing featuring executives from major PBMs.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers. They negotiate prices with pharmaceutical companies and determine patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (CVS Health)—control around 80% of American prescriptions.
The committee’s investigation revealed that PBMs often develop lists of preferred medications that favor pricier brand-name drugs over less expensive alternatives. For instance, the report mentioned communication from Cigna employees discouraging the use of more affordable substitutes for Humira, an arthritis treatment that costs upwards of $90,000 annually, despite the availability of a biosimilar for half that price.
Additionally, Express Scripts reportedly informed patients that filling a prescription at local pharmacies would be costlier than obtaining a three-month supply from its mail-order service, thereby constraining patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, stating that major PBMs dominate nearly 95% of prescriptions filled in the country due to increasing consolidation. The FTC warns that this dominance allows PBMs to wield substantial influence over the accessibility and affordability of prescription medications in the U.S. It also pointed out that these vertically integrated PBMs may favor their own subsidiaries, thus creating conflicts of interest that could harm independent pharmacies and escalate drug prices.
FTC Chair Lina M. Khan remarked that the findings indicate these intermediaries are charging patients excessive amounts for cancer medications, generating over $1 billion in extra revenue.